Visante 
Many of you may be experiencing another tidal wave of surges with the Omicron Covid-19 variant. Though we have been fighting the pandemic for almost two years, each surge seems to bring new battles. The NIH recently published new outpatient therapy guidelines to help combat the Omicron variant; as well as, we have received a few questions from our readers on how to handle the billing changes.
Remdesivir is now among one of the treatment options for non-hospitalized patients when Omicron is the predominant circulating variant. CMS has designated HCPCS code J0248, injection remdesivir, 1 mg. The code is effective for dates of service beginning December 23, 2021 and may be used to rebill any previously administered outpatient remdesivir account.
Remdesivir is FDA approved for hospitalized patients and utilizing remdesivir for outpatients is considered off-labeled. It is prudent to ensure patients meet the criteria outlined by the NIH to avoid any denials by the MACs. If denied for payment, following the appeal process to overturn any remdesiver when used according to recommendations. Note, Medicare beneficiaries will be responsible for the 20% deductible for the drug and administration of remdesivir.
Currently, J0248 code for remdesivir has not been updated in the Outpatient Code Editor (OCE). Payers may not be able to process claims until this update has occurred. In which case, it may be advantageous to hold claims temporarily until the payers are ready to accept the newly created code.
Other updates for Covid-19 Vaccine and Monoclonal Antibodies
Effective January 1, 2022, Original Medicare (or Medicare Fee for Service) will no longer cover the vaccine or monoclonal antibodies on behalf of the Medicare Advantage (MA) plans. MA claims should have split any vaccine or covid related monoclonal antibodies to be billed to the Original Medicare plan. This claim split should be “undone” for any claims billed out after January 1, 2022. MA and Medicare plans will continue to cover the vaccine and monoclonal antibodies respectively once billed.
Shout Outs!
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Pharmacy Revenue Cycle and Informatics Teams should update the CDM for remdesivir to reflect the new code J0248, injection 1 mg.
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Revenue Integrity teams should conduct an audit of any outpatient account who utilized remdesivir from dates of service December 23, 2021 to rebill accounts when used in accordance to the NIH guidelines.
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Revenue Integrity and Billing teams should monitor claims to ensure claim processing software at the MAC is accepting the new remdesivir code and may consider holding claims until they process cleanly.
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Billing teams should ensure that for dates of service Covid-19 vaccines and monoclonal antibody infusions prior to 2022 were billed to the Original Medicare for payment. Claims logic should be undone to allow for the traditional billing to both MA and Original Medicare.
Our goal is simple; we’re taking complex information and making it practical.
Until our next edition, this is Maxie Friemel and Agatha Nolen providing you with tips for increasing your Pharmacy Revenue.
